Provider Demographics
NPI:1760718282
Name:SMITH, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3285 OAKLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-3807
Mailing Address - Country:US
Mailing Address - Phone:731-698-1061
Mailing Address - Fax:
Practice Address - Street 1:80 ENOCH BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372
Practice Address - Country:US
Practice Address - Phone:731-926-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000161004163WC1500X
TN24523363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health